某三甲专科医院不良事件管理现状及对策分析

Status Quo and Countermeasures Analysis of Adverse Event Management in a Tertiary Specialist Hospital

目的整理分析医院医疗安全(不良)事件统计数据,为进一步提高医院精细化管理水平提供决策依据。方法对2016年至2017年不良事件上报的类型、原因、级别等进行回顾性统计,分析不良事件管理的成功经验和存在的不足,探讨下一步决策方向。结果医院不良事件上报情况良好,对事件的归口职能部门、分类标准、分级标准有明确且适用的规定;多部门协同管理的不良事件均已得到妥善处理,且后续持续改进效果评价良好。多部门协同管理不良事件的例数较少,影响面有限(共14例,占1.14%)。对于Ⅳ级事件(由于及时发现错误,未形成事实)的识别和上报管理不足,需进一步加强管理。结论对不良事件管理体系进行标准化,减少管理成本;加强多部门协作管理,提升持续改进效果;加强患者安全文化建设,提高不良事件上报数量,以不良事件管理为抓手,提高医院精细化管理水平。

Objective To analyze the statistical data of medical safety adverse events in the hospital,and to provide reference for improving the level of fine management.Method The types,causes,and grades of adverse event reports from 2016 to 2017 were retrospectively reviewed and analyzed to explore the successful experiences and shortcomings of adverse event management,and to explore future decision direction.Results The reports of adverse events in the hospital was good with clear and applicable regulations on the responsible functional departments,and classification and grading standards of the events.Adverse events collaboratively managed by several departments were properly dealt with and the effect of continuous improvement was well.But there were only a few cases,having limited influence(14 cases,1.14%).Grade-IV events(no fact due to the timely discovery of errors)were not adequately identified and reported.Conclusion To improve the level of fine management,the hospital should stress on adverse event management by standardizing the adverse event management system to reduce management costs;strengthening collaborative multi-department management to improve the effect of continuous improvement;and strengthening the construction of patient safety culture to increase the number of event reports.